Battaglini Denise, Anania Pasquale, Rocco Patricia R M, Brunetti Iole, Prior Alessandro, Zona Gianluigi, Pelosi Paolo, Fiaschi Pietro
Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.
Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy.
Front Neurol. 2020 Nov 24;11:564751. doi: 10.3389/fneur.2020.564751. eCollection 2020.
Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step "staircase approach" which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2-12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15-90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.
重度创伤性脑损伤（TBI）常伴有颅内压（ICP）升高，继而导致脑灌注压（CPP）降低。建议采用有创颅内压监测来指导逐步的“阶梯式治疗方法”，该方法旨在使颅内压值恢复正常并降低继发性损伤风险。然而，如果无法进行这种监测，则应使用临床检查和影像学标准。一个主要问题是如何逐渐减少用于控制颅内压的治疗方法。本文的目的是回顾TBI患者治疗升级和撤药的标准。阶梯式治疗方法的每一步都存在与治疗持续时间相关的不良反应风险。一旦颅内压得到控制至少24小时，就应开始逐渐减少巴比妥类药物的用量，不过通常需要2至12天的时间。如果颅内压正常，应避免使用高渗液体。在颅内压得到控制至少24小时后，应减少镇静剂量以便进行神经学检查。颅内压正常72小时后，建议移除有创颅内压监测装置。对于接受过手术减压的患者，颅骨成形术是最后一步，早期颅骨成形术（减压后15至90天）似乎可降低感染、癫痫和脑积水的发生率。
